Provider Demographics
NPI:1629770904
Name:PETTITT, JATHANIEL A (LPCC)
Entity Type:Individual
Prefix:MR
First Name:JATHANIEL
Middle Name:A
Last Name:PETTITT
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17378 W PIMA ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1962
Mailing Address - Country:US
Mailing Address - Phone:972-841-9262
Mailing Address - Fax:
Practice Address - Street 1:12900 PARK PLAZA DR
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-9329
Practice Address - Country:US
Practice Address - Phone:305-630-1346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-19640101YM0800X, 101YP2500X
TX66158101YM0800X, 101YP2500X
CALPCC10824101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional